Humana USAA Honor Giveback (PPO)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45
Prior Authorization Required for Doctor Specialty Visit

In-Network:

Acute Hospital Services:
$500 per day for days 1 to 4
$0 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $40

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40

Emergency Care:
Copayment for Emergency Care $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $115
Copayment for Worldwide Emergency Transportation $325

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $325

Air Ambulance:
Copayment for Air Ambulance Services $1800
Prior Authorization Required for Air Ambulance

In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 30%

Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 10% to 50%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 50%

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $40
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30% to 50%
Coinsurance for Medicare Covered Lab Services 50%
Copayment for Medicare Covered Diagnostic Radiological Services $0
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30% to 50%
Copayment for Medicare Covered Outpatient X-Ray Services $40
Coinsurance for Medicare Covered Outpatient X-Ray Services 30% to 50%
$100 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC$175 Sleep Study (Fac Based) - OPH$100 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 50%

Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 50%

Out-of-Network:

Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $550
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$0 Mental Health - OPH$550 Surgery Svcs - OPH$45 Wound Care - OPH

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $500
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $450
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$450 Surgery Svcs - ASC

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 30% to 50%
Coinsurance for Medicare Covered Group Sessions 30% to 50%
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

In-Network:
$25 quarterly allowance on a prepaid spending card to buy approved over-the-counter health and wellness products at participating retail locations or through the plan's approved OTC mail order vendor.
Unused amount expires at the end of the quarter or upon disenrollment from the plan, whichever occurs first.

Out-of-Network:
95% coinsurance.
Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45
Prior Authorization Required for Podiatry Services

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 50%

In-Network:
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays up to 1 per year.
$0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$25 copayment for amalgam and/or composite filling up to 2 per year.
$1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Out-of-Network:
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays up to 1 per year.
$0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$25 copayment for amalgam and/or composite filling up to 2 per year.
$1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $45
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
$0 Diab Eye Exam - All POTs$45 Vision Svcs (MC) - SPC

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0

• Maximum 1 Pair every year

Copayment for Eyeglasses (lenses and frames) $0

• Maximum 1 Pair every year

Maximum Plan Benefit of $100 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network.

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 4 visits every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $575 to $750

• Maximum 2 Hearing Aids every year

Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0